Enteral Tubes: Enteral Feeding Management Best Practice

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Enteral Tubes Enteral Feeding Management Best
Practice
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• Metropolitan Working Party 2007
• Endorsed by Chief Nursing Officer of Western
  Australia

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Power point options

• Section 1- Essential changes to enteral tube
  management
• Section 2 Overview of Enteral Tubes Enteral
  Feeding Nursing Practice Standard (NPS)

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Section 1

• Essential changes to enteral tube management

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Critical incident reports

• 2005 a sentinel event in a WA tertiary hospital
• UK findings- 11 deaths over a two year period,
  due to misplaced nasogastric tubes (NGT) 1
• Areas of concern
• Reliability of methods to assess tube placement
• Validity of litmus paper test
• Reliability of whoosh test

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Challenge to nursing care

• Practice to reflect current best practice
  recommendations
• To standardise nursing practice and documentation
• To optimise patient outcomes through risk
  reduction

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WA response

• Metropolitan collaboration (FH, PMH, RPH, SCGH,
  SGOJ)
• Investigation of existing practices
• Literature review and recommendations
• Confirmation of key areas of change
• Development of nursing practice standard
  metropolitan wide
• Education and audit

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Key areas of change

• Do NOT carry out auscultation or whoosh test to
  assess NGT position as unreliable
• Do NOT use litmus paper as false results (the
  lungs can have an acidic content to give positive
  litmus reading 1)
• Criteria for NGT selection

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Key areas of change

• Auscultation and Whoosh test replaced by
• Confirmation of NGT placement by X-ray1
  (radiation exposure)
• OR
• An aspirate result of pH lt5.5 with introduction
  of pH specific indicator strips (will exclude
  pulmonary placement 1,2)

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Criteria for NGT selection

• Tubes recommended to include the following
  features
• Be radiopaque (X-ray detection)
• Have multiple ports (air port - to aid
  aspiration)
• Display clear centimetre line markers present
  (tube placement)
• Have caps attached (Close ports when they are not
  in use)
• Be available in a variety of materials which
  cater for different clinical situations
  medications, allergies
• Be available in a number of lengths and sizes 3

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Best practice

• NEVER place anything into a NGT
• unless
• the tip is confirmed as being in the stomach

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Caution

• Nurses are not permitted to insert a NGT into
  patients with possible or confirmed facial/skull
  fractures (risk of insertion into cranium via
  fracture sites 4,5)
• No more than 3 attempts at NGT insertion are to
  be made by one Nurse 6
• Liaise with Medical staff

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Conclusion

• Never place anything into the NGT unless
  placement is confirmed
• Confirm NGT placement by X-ray OR an aspirate
  result of pH lt5.5 using pH specific indicator
  strips
• Recommended criteria for NGT selection
• Refer to Enteral Tubes Enteral Feeding Nursing
  Practice Standard for detailed information

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Section 2

• Overview of Enteral Tubes Enteral Feeding
• Nursing Practice Standard (NPS)

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Nasogastric tube (NGT) measurement

• Measure the selected tube from
• Nose tip to ear lobe
• Ear lobe to xiphoid process of sternum
• Note the required length by attaching a piece of
  tape to the tube
• NB Silastic tubes must be measured from the
  weight and not the tube tip.

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NGT insertion documentation to include

• Date time
• Reason for insertion
• Type of tube
• Size of tube
• Length of tube
• Nostril tube inserted
• Number of attempts required

• Additional comments
• Any complications
• Method of placement confirmation
• Signature name designate of Nurse inserting
  tube

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Assessing NGT Placement

• Aspirate NGT using pH indicator strips- non
  bleeding blue litmus paper is not sensitive
  enough to distinguish between bronchial and
  gastric secretions 1 (pH of 5.5 or below will
  exclude pulmonary placement 1,2)
• Assess tube length- compare to documented tube
  length to determine migration
• X-ray shows radio opaque placement of NGT
  (Limitations exposure to radiation)

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Frequency of checking placement

• Following insertion
• Prior to each bolus feeding
• Following a break in continuous feeding
• Prior to medication administration
• After oropharyngeal suction
• Coughing fit

• Alteration of external length of tube
• Post vomiting
• Complaining of discomfort or feed reflux in
  throat/mouth
• Sudden signs of respiratory distress
• Interdepartmental transfer

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Aspirate pH above 5.5

• Check external tube length
• Instigate Multidisciplinary Management Team Risk
  Assessment
• Wait 1 hour post last feed (dilution of gastric
  acid by the enteral feed causes higher pH1)
• Check medications (some can increase level of
  gastric contents H2 antagonists, proton pump
  inhibitors antacids 7)

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No gastric aspirate obtained

• If appropriate, X-ray to confirm placement
• Clear NGT insufflate 10-20mL air into NGT
  aspirate test pH
• Reposition pt onto side ? wait 15-30 mins (allows
  tip to enter gastric pool), repeat aspiration
  test pH
• Reposition NGT advance NGT 10-20cm (inserted too
  far it may be in duodenum7) aspirate test pH.
• - Remember to document new external length

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Gastric residual volume

• Volume gt300mL
• Return 300mL of aspirate
• Continue feeding
• At next aspirate repeat above 2 steps if volume
  is gt300mL notify RMO
• Review hypoglycaemic medications (insulin) if
  appropriate
• Position head up 30-45 degrees
  (unless contraindicated)

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Gastric residual volume (contd)

• Volume lt300mL
• Return aspirate
• Continue feeding
• Position patient head up 30-45 degrees (unless
  contraindicated)

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Medication administration

• Consult with Pharmacist to determine
• If liquid preparation available
• Drug compatibilities if administering multiple
  medications at the same prescribed time
• Timing of medication administration as some
  interact with enteral formula (phenytoin,
  warfarin, ciprofloxin 8)

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Medication administration

• All medications must be administered via gravity
  flow do not use the plunger to force medication
  down the NGT
• Do NOT add medications to feeding formula
  (Exception certain electrolyte solutions
  multivitamins)
• Flush NGT with 20 -30mL room temperature tap
  water pre and post medication administration
  (unless immuno-compromised use sterile water and
  syringe)

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Known drug incompatibility

• Liaise with Pharmacist
• Administer separately using dedicated syringe for
  each specific medication
• Flush between each medication administered

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Removal of NGT

• Liaise with Medical staff to confirm removal
• Disconnect drainage bag or feeding device
• Insufflate 10-20mL (adult), 1-5mL (child) of air
  into NGT
• Ask pt to take a deep breath (where appropriate)
• Coil the tube around gloved hand while pulling
  slowly and evenly over 3-6 seconds
• Document as per NPS

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Conclusion

• Never place anything into the NGT unless
  placement is confirmed
• Confirm NGT placement by X-ray OR an aspirate
  result of pH lt5.5 using pH specific indicator
  strips
• Recommended criteria for NGT selection
• Refer to Enteral Tubes Enteral Feeding Nursing
  Practice Standard for detailed information

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Questions?
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References

• National Patient Safety Agency Alert. Reducing
  the harm caused by misplaced nasogastric feeding
  tubes. NHS 21 February, 2005.
• Khair J. Guidelines for testing the placing of
  nasogastric tubes. Nursing Time 2005 101(20)
  26-27.
• Metcalf S. Nasogastric Tube Clinical Audit. 12th
  July 2006. Cross Hospital Review of Practice.
  Royal Perth Hospital Report unpublished.
• Methany NA, Meert KL. Monitoring feeding tube
  placement Nutrition in Clinical Practice 2004
  19 487- 595.
• Genu PR et al. Inadvertent intracranial placement
  of a nasogastric tube in a patient with severe
  craniofacial trauma A case report. Journal of
  Oral Maxillofacial Surgery 2004 621435-1438.
• Best C. Caring for the patient with a nasogastric
  tube. Nursing Standard 2005 2(3)59-65.
• Holmes J et al Guidelines for the management of
  enteral feeding in adults, Clinical Resource
  Efficiency Team (CREST) April 2004
• Joanna Briggs Acute Care Manual. Administration
  of enteral medications. May 2005.